Exploring COVID-19 vaccine uptake among healthcare workers in Zimbabwe: A mixed methods study

With COVID-19 no longer categorized as a public health emergency of international concern, vaccination strategies and priority groups for vaccination have evolved. Africa Centres for Diseases Prevention and Control proposed the ‘100-100-70%’ strategy which aims to vaccinate all healthcare workers, all vulnerable groups, and 70% of the general population. Understanding whether healthcare workers were reached during previous vaccination campaigns and what can be done to address concerns, anxieties, and other influences on vaccine uptake, will be important to optimally plan how to achieve these ambitious targets. In this mixed-methods study, between June 2021 and July 2022 a quantitative survey was conducted with healthcare workers accessing a comprehensive health check in Zimbabwe to determine whether and, if so, when they had received a COVID-19 vaccine. Healthcare workers were categorized as those who had received the vaccine ‘early’ (before 30.06.2021) and those who had received it ‘late’ (after 30.06.2021). In addition, 17 in-depth interviews were conducted to understand perceptions and beliefs about COVID-19 vaccines. Of the 3,086 healthcare workers employed at 43 facilities who participated in the study, 2,986 (97%, 95% CI [92%-100%]) reported that they had received at least one vaccine dose. Geographical location, older age, higher educational attainment and having a chronic condition was associated with receiving the vaccine early. Qualitatively, (mis)information, infection risk perception, quasi-mandatory vaccination requirements, and legitimate concerns such as safety and efficacy influenced vaccine uptake. Meeting the proposed 100-100-70 target entails continued emphasis on strong communication while engaging meaningfully with healthcare workers’ concerns. Mandatory vaccination may undermine trust and should not be a substitute for sustained engagement.


INTRODUCTION
Coronavirus disease 2019 (COVID-19) vaccines have been a key pillar of the pandemic response at 74 global, national, and local levels. Their roll-out has reduced morbidity, severity and deaths [1][2][3]. 75 However, vaccine nationalism and global unequal vaccine distribution limited the availability of COVID-76 19 vaccines, especially in low-and middle-income countries (LMICs) [4,5], resulting in slow and often 77 erratic roll out [5]. In response to vaccine nationalism and accessibility challenges, various international 78 platforms were created to increase vaccine availability in LMICs, including the COVID-19 vaccine delivery  To optimize the use of limited and often unpredictable supply of vaccines, Zimbabwe like many LMICs 86 used a phased approach that prioritized at-risk groups for vaccination, including healthcare workers [8,9]. 87 Prioritizing and ensuring high vaccine uptake among healthcare workers was important for several 88 reasons. First, healthcare workers were widely recognized as being at heightened risk of COVID-19, as 95 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted July 23, 2023. perceptions, anxieties, and concerns to reach the ambitious 100% target. Strategies to achieve universal 104 vaccine coverage will likely need to be context-sensitive and informed by actual uptake data during the 105 pandemic. In this mixed-methods study, we sought to understand vaccine uptake, perceptions, and 106 attitudes among healthcare workers in Zimbabwe.

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Study design 110 Data was collected as part of a study providing a comprehensive health check to healthcare workers in 111 Zimbabwe which has been described in detail elsewhere [19]. A quantitative survey and in-depth 112 interviews were conducted with selected healthcare workers accessing the service between June 2021 113 and July 2022.  116 Zimbabwe is a low-income country with a long history of severe economic decline affecting healthcare 117 services, public health programmes, and epidemic management capacity [20,21]. During the study 118 period, healthcare workers had taken up industrial action over low wages and unavailability of adequate 119 personal protective and medical equipment [20,22]. The study was conducted in public hospitals across 120 all ten provinces in Zimbabwe and primary care clinics in Harare, Matabeleland North, and Mashonaland . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.    . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

Study setting and population
The copyright holder for this preprint this version posted July 23, 2023. For the in-depth interviews, healthcare workers were purposively selected (after accessing the health 152 check) based on their vaccination status, the time of their first vaccination dose and the place they 153 worked. A total of 17 in-depth interviews were conducted, after reaching a data saturation point [29]. A 154 topic guide was developed prior to the interview and included questions about participants' vaccination 155 status, challenges of accessing vaccines, concerns about vaccine safety, reasons for being vaccinated 156 or not, and sources of information to guide decision-making. During interviews, participants were given a 157 broader remit to discuss more general concerns and anxieties, as well as why there were these concerns  is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 23, 2023. ; https://doi.org/10.1101/2023.07.17.23292791 doi: medRxiv preprint 171 variable was receiving the vaccine 'early' or 'later'. Healthcare workers categorised as receiving the 172 vaccine "early" were defined as having received the first vaccine dose between 22 nd of February and 30 th 173 of June 2021, while somebody receiving the first vaccine dose after June 2021 was categorised as "late". one or iii) two or more co-morbidities. Co-morbidities which were ascertained through self-report included:

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In-depth interviews were audio-recorded, transcribed, and translated. During the interview, research 189 assistants took field notes and wrote interview summaries at the end of the day. Transcripts and other 190 qualitative data (i.e., field notes and interview summaries) were imported into the qualitative data analysis 191 software NVivo 12, which was used to perform thematic analysis. Thematic analysis was performed on 192 an ongoing basis synchronously and after data collection. Using the principles of grounded theory, [29] 193 we fed working hypotheses generated from interim analysis into the ongoing collection of data. This 194 created progressively broader and more encompassing themes to explain and theorise findings.
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A total of 2905 healthcare workers from 37 health facilities accessed the service during the study period, 209 half of which worked at facilities in Harare and Bulawayo provinces (Table 1)  CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 23, 2023.  Participants generally felt that the government had run an effective information campaign using radio, 235 television, billboards, and banners. The information provided, they felt, was reliable, accurate, and easy 236 to understand, and included messages encouraging the population to get vaccinated. However, it was 237 highlighted that information was not always communicated in all languages, which impacted the 238 accessibility of information.   This was supported by the quantitative data (Fig 2) showing that the most frequently reported reason for 254 not being vaccinated was pregnancy, breastfeeding or trying to conceive (34/87, 39%), followed by fear 255 of side effects (13/87, 15%).

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. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. While some participants felt that the government had provided reliable information about the vaccines, 262 most participants reported the internet and social media being their main sources of information.

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However, they acknowledged that these sources also spread false information. It was felt that 264 misinformation was an important factor preventing or hindering people to get vaccinated.  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 23, 2023.   When probing for detail, healthcare workers voiced some concerns regarding vaccine safety, specifically 302 due to side effects. While none of the interviewed healthcare workers had experienced side effects 303 themselves, they said that some of their friends, colleagues, and family members had experienced 304 symptoms which they believed were due to vaccination.
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The copyright holder for this preprint this version posted July 23, 2023. ; https://doi.org/10.1101/2023.07.17.23292791 doi: medRxiv preprint 305 "[L]ike there is this nurse that I saw, she had a reaction; she had some sort of funny reaction as 306 if it was like burns. I don't know but she had a reaction, so that on its own is a push factor. She 307 had some complications, and she was admitted, that's a push factor, when people tell you that 308 they have reacted". (Clinician, Early Receiver, Bulawayo) 309 The origin (China) of the vaccine was also raised as a cause of concern, specifically because China was 310 the origin of the pandemic and due to theories that the pandemic was man-made.   Some institutions, especially those run by the government, mandated their employees to be vaccinated.

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In addition, statements were made that unvaccinated people would not be paid or denied entry into 354 workplaces. Some people accessed vaccination because of work requirements.
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The copyright holder for this preprint this version posted July 23, 2023.  . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
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(which was not certified by peer review)
The copyright holder for this preprint this version posted July 23, 2023.  (Clinician, Early Receiver, Harare). 408 However as for healthcare workers themselves, very few reported that the reason for not getting 409 vaccinated were logistical reasons such as long waiting time 9% (n=8) and vaccine stocks 1% (n=1).     extra layer of protection. Generally, those who were objectively at higher risk of severe disease (such as 469 older people, people with obesity and/or co-morbidities) were more likely to be vaccinated earlier. This 470 may be due to their own perceived higher risk, or it may be due to initial prioritisation of these at-risk 471 groups among healthcare workers and also an effect of the RCCE campaign. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted July 23, 2023.   The strengths of this study lie in the use of a mixed-method approach investigating self-reported vaccine 499 uptake and associated reasons. The sample size was large both with regards to the number of healthcare 500 workers included and the number of health facilities, with the latter including a diverse range of health 501 facilities from tertiary to primary level and across different provinces. The limitations include that 502 vaccination was self-reported and not verified by checking vaccination cards and thus may have been . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 23, 2023. ; https://doi.org/10.1101/2023.07.17.23292791 doi: medRxiv preprint 503 subject to social desirability and/or recall bias (specifically the date of vaccination). Also, healthcare 504 workers were self-selected from those who came forward to access the health check-up service. This 505 may have introduced selection bias as those healthcare workers who took up the health check service 506 may have been more health conscious and thus more likely to be vaccinated.   Mrs. Lillian Mususa, and the BRTI team and most importantly the participants who spared their time to 540 share this valuable experience.

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. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted July 23, 2023. ; https://doi.org/10.1101/2023.07.17.23292791 doi: medRxiv preprint